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General NPI Number Information
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NPI Number | 1528838372
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Entity Type | Organization
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Legal Business Name | ICOM BAY HARBOR LLC
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 1160 KANE CONCOURSE STE 203
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City | BAY HARBOR ISLANDS
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State | FL
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Zip | 33154-2020
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Country | US
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Telephone | 305-560-5859
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Fax |
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Provider Business Mailing Address
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Address Line | 611 NE 13TH ST
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City | FT LAUDERDALE
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State | FL
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Zip | 33304-1109
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Country | US
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Telephone | 786-713-9290
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | TATIANA SANTIAGO HERZOG
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Credential | DDS
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Telephone | 305-560-5859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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